Nepal's national health insurance program was introduced to make healthcare more accessible and affordable for its citizens. While it has made progress over the years, many challenges still exist—especially in how claims are managed. Based on my experience working in the field and with health policy, I’ve seen that the core problem isn’t lack of effort or funding, but rather outdated digital systems—particularly the limitations of the current Integrated Management Information System (IMIS).
The Current Scenario: IMIS and Its Limitations
Nepal currently uses IMIS (Integrated Management Information System) to administer its health insurance program. Originally designed for administrative and social protection tasks, IMIS has played a valuable role in managing beneficiary records, insurance cards, and basic claims submissions. However, it is fundamentally not designed for dynamic claims processing, real-time communication, or tracking workflows—critical features in a high-volume, medically sensitive context like health insurance.
Hospitals frequently report being stuck with unresolved or incomplete claims, and the lack of automated verification and feedback mechanisms means processors at the Health Insurance Board (HIB) are overwhelmed. As it stands, IMIS is more of a static record-keeping tool than a responsive, intelligent processing system.
Learning from Others: Global Best Practices
Countries like India, Germany, and Rwanda offer valuable lessons. India, with a population nearly 46 times larger than Nepal and around 38% of it enrolled in government health insurance, successfully uses a Transaction Management System (TMS) under its flagship Pradhan Mantri Jan Arogya Yojana (PM-JAY). The TMS handles real-time claims submissions, auto-verification, two-way communication, and analytics.
Germany, home to the world’s oldest and most successful health insurance model, relies on a standardized electronic claims system (GKV) to manage billions of euros in reimbursements every year with near-perfect accountability. Rwanda, comparable to Nepal in terms of economy and digital infrastructure, has adapted the openIMIS framework and layered it with a simplified TMS to improve accountability and transparency across its Mutuelle de Santé program.
What Would an Ideal TMS Look Like for Nepal?
A Transaction Management System (TMS) is not just a claims tool—it is a full ecosystem for tracking, validating, and managing insurance processes in real time. For Nepal, an ideal TMS would ensure that no claim is submitted until all mandatory documents are attached. Incomplete submissions would remain flagged in the hospital dashboard, allowing for prompt correction. This minimizes disputes and improves transparency.
The system should include distinct login access for hospitals, HIB staff, auditors, and medical verifiers. Each claim would pass through pre-medical verification to ensure completeness before reaching the medical audit stage. Real-time tracking, query and response modules, and performance-based accountability would bring much-needed structure to the current free-flow model.
Moreover, a well-designed TMS is not static. It must evolve. Built-in adaptability would allow the system to accommodate policy changes, package updates, and analytic insights over time.
Turnaround Time: Accountability for All
Currently, only hospitals are bound by a 7-day turnaround time (TAT) to submit claims after service delivery. HIB, however, has no defined TAT for claim review, query, or payment decision. This one-sided accountability often leads to delays, inefficiencies, and frustrations on the provider side.
A robust TMS would incorporate stage-wise TATs for both hospitals and the HIB. For example:
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Hospital to submit claim: within 7 days
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HIB to raise queries or accept claim: within 5 working days
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Hospital to respond to queries: within 5 working days
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Final decision/payment: within 15 working days
Such clarity ensures shared responsibility and helps build trust among all stakeholders.
Cost and Feasibility: A Realistic Investment
While I do not possess exact cost figures, it would not take much effort for the government to consult local IT firms and development partners to get reliable estimates. Nepal has a growing pool of capable software companies with experience in building enterprise-level systems. Through a competitive bidding process, a robust TMS could likely be developed and deployed with an estimated investment of NPR 20–30 million (approx. USD 150,000–230,000), with annual maintenance under NPR 4 million.
Given the scale of inefficiencies currently affecting the system, this investment would be justified many times over by the improvements in speed, transparency, and public confidence.
Conclusion: IMIS + TMS = The Smart Hybrid
IMIS has contributed significantly to Nepal’s health insurance infrastructure in terms of administrative record-keeping. But it cannot and should not be stretched to handle medically sensitive and technically demanding tasks like claims processing. The solution is not to discard IMIS, but to complement it.
A hybrid model—where IMIS handles administrative functions and TMS manages the dynamic claims process—offers the best path forward. With clear accountability mechanisms, responsive user interfaces, and continuous system improvements, TMS could become the cornerstone of a health insurance program that works better for everyone: hospitals, administrators, and most importantly, the Nepali people.
